Quality Improvement Change Assessment

Transcription

1 HLC 1: EMBED CLIN ICA L EV IDEN C E ON ABCS INTO DA I LY WORK TO G U IDE CARE FOR PAT IE N TS 1. Comprehensive, guideline-based information on prevention or chronic illness treatment is not readily available in practice. is available but does not influence care. is available to the team and is integrated into care protocols and/or reminders. guides the creation of tailored, individual-level data that is available at the time of the visit. HLC 2: UT IL I ZE REL IAB LE, R OBU S T DATA TO UNDER STA ND AND I MPROVE ABCS MEA SU R E S 2. Performance measures are not available for the clinical site. are available for the clinical site, but are limited in scope. are comprehensive including clinical, operational, and patient experience measures and available for the practice, but not for individual providers. are comprehensive including clinical, operational, and patient experience measures and fed back to individual providers. 3. Reports on care processes or outcomes of care are routinely provided as feedback to practice teams but not reported externally. are not routinely available to practice teams. are routinely provided as feedback to practice teams, and reported externally (e.g., to patients, other teams or external agencies) but with team identities masked. are routinely provided as feedback to practice teams, and transparently reported externally to patients, other teams and external agencies.

2 HLC 3: ESTAB L IS H A R EG U LAR QI PR OC ES S INVOLV IN G CROSS-FUNC TIONA L TEAMS 4. The responsibility for conducting quality improvement activities is not assigned by leadership to any specific group. is assigned to a group without committed resources. is assigned to an organized quality improvement group who receive dedicated resources. is shared by all staff, from leadership to team members, and is made explicit through protected time to meet and specific resources to engage in QI. 5. Quality improvement activities are conducted on an ad hoc basis in reaction to specific problems. are not organized or supported consistently. are based on a proven improvement strategy in reaction to specific problems. are based on a proven improvement strategy and used continuously in meeting organizational goals. 6. Quality improvement activities are conducted by a centralized committee topic specific QI or department. committees. all practice teams supported by a QI infrastructure. practice teams supported by a QI infrastructure with meaningful involvement of patients and families.

3 HLC 4: ID ENT I FY AT-RISK PAT IE NT S F OR PR EV ENT IO N OUTR EAC H 7. Registry or panel-level data are not available to assess or manage care for practice populations. are available to assess and manage care for practice populations, but only on an ad hoc basis. are regularly available to assess and manage care for practice populations, but only for a limited number of diseases and risk states. are regularly available to assess and manage care for practice populations, across a comprehensive set of diseases and risk states. 8. Registries on individual patients are not available to are available to practice are available to practice are available to practice practice teams for pre-visit teams but are not teams and routinely used teams and routinely used planning or patient routinely used for pre-visit for pre-visit planning or for pre-visit planning and outreach. planning or patient patient outreach, but only patient outreach, across a outreach. for a limited number of comprehensive set of diseases and risk states. diseases and risk states. 9. A standard method or tool(s) to stratify patients by risk level is not available. is available but not consistently used to stratify all patients. is available and is consistently used to stratify all patients but is inconsistently integrated into all aspects of care delivery. is available, consistently used to stratify all patients, and is integrated into all aspects of care delivery.

4 10. Visits largely focus on acute problems of patient. are organized around acute problems but with attention to ongoing illness and prevention needs if time permits. are organized around acute problems but with attention to ongoing illness and prevention needs if time permits. The practice also uses subpopulation reports to proactively call groups of patients in for planned care visits. are organized to address both acute and planned care needs. Tailored guideline-based information is used in team huddles to ensure all outstanding patient needs are met at each encounter. HLC 5: DEFI NE R OL E S AND RESP ON S IBILI TIES ( TASKS) ACROSS THE C ARE T EA M TO ID ENT IF Y AND MANA G E ABCS 11. Non-physician practice play a limited role in team members providing clinical care. are primarily tasked with managing patient flow and triage. provide some clinical services such as assessment or selfmanagement support. perform key clinical service roles that match their abilities and credentials. 12. The practice does not have an organized approach to identify or meet the training needs for providers and other staff. routinely assesses training needs and ensures that staff are appropriately trained for their roles and responsibilities. routinely assesses training needs, ensures that staff are appropriately trained for their roles and responsibilities, and provides some cross training to permit staffing flexibility. routinely assesses training needs, ensures that staff are appropriately trained for their roles and responsibilities, and provides cross training to ensure that patient needs are consistently met.

5 13. Care Plans are not routinely developed or recorded. 14. Clinical care management services for high-risk patients are developed and recorded but reflect providers priorities only. are developed collaboratively with patients and families and include self-management and clinical goals, but they are not routinely recorded or used to guide subsequent care. are developed collaboratively, include self-management and clinical management goals, are routinely recorded, and guide care at every subsequent point of service. are not available. are provided by external care managers with limited connection to practice. are provided by external care managers who regularly communicate with the care team. are systematically provided by the care manager functioning as a member of the practice team, regardless of location. HLC 6: DEEP EN PATIEN T SEL F-MAN A GE M ENT S U PPOR T F OR ACT IO N PLANNING A R OUND ABCS 15. Assessing patient and family values and preferences is not done. is done, but not used in planning and organizing care. is done and providers incorporate it in planning and organizing care on an ad hoc basis. is systematically done and incorporated in planning and organizing care.

6 16. Involving patients in decision-making and care is not a priority. is supported and documented by practice teams. is accomplished by provision of patient education materials or referrals to classes. is systematically supported by practice teams trained in decisionmaking techniques. 17. Self-management support is limited to the distribution of information (pamphlets, booklets). is accomplished by referral to selfmanagement classes or educators. is provided by goal setting and action planning with members of the practice team. is provided by members of the practice team trained in patient empowerment and problem-solving methodologies. HLC 7: DEV EL OP ROBU ST LIN KA G ES TO S MOK I NG C E S SAT ION, CDSMP AND OT HER EV ID EN CE-BASED COMMU NITY R ES O U RCES 18. Test results and care are not communicated plans to patients. are communicated to patients based on an ad hoc approach. are systematically communicated to patients in a way that is convenient to the practice. are systematically communicated to the patients in a variety of ways that are convenient to patients.

7 19. Patients in need of specialty care, hospital care, or supportive community- based resources cannot reliably obtain needed referrals to partners with whom the practice has a relationship. obtain needed referrals to partners with whom the practice has a relationship. obtain needed referrals to partners with whom the practice has a relationship and relevant information is communicated in advance. obtain needed referrals to partners with whom the practice has a relationship, relevant information is communicated in advance, and timely follow-up after the visit occurs. 20. Linking patients to supportive community- based resources is not done is limited to providing is accomplished through is accomplished through systematically. patients a list of identified a designated staff person active coordination community resources in or resource responsible for between the health an accessible format. connecting patients with system, community community resources. service agencies and patients and accomplished by a designated staff person.